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Transcutaneous Parasacral Electrical Neural Stimulation in Children with Primary Monosymptomatic Enuresis: A Prospective Randomized Clinical Trial
Liliana Fajardo de Oliveira, Dayana Maria de Oliveira, Lidyanne Ilídia da Silva de Paula, André Avarese de Figueiredo, José de Bessa Jr., Cacilda Andrade de Sá, José Murillo Bastos Netto
Journal of Pediatric Urology, Volume 12, Issue 2, April 2016, Pages 112.e1–112.e6
Commented by Konstantinos Kamperis
Although we substantial knowledge is gained during the last decades the treatment of monosymptomatic nocturnal enuresis can still be a challenging task with up to 40% of the patients not responding to first line treatments such as desmopressin and conditioning with the enuresis alarm.
Transcutaneous electrical neural stimulation is an effective treatment modality for overactive bladder. The authors investigate the efficacy of TENS in the treatment of monosymptomatic nocturnal enuresis. The rational for treatment with TENS is that a number of children with nocturnal enuresis and no daytime symptoms do present with bladder reservoir issues during sleep.
The authors test TENS treatment given as 10 sessions combined with behavioral therapy against behavioral therapy alone. A total of 45 children older than 6 years were recruited.
Although a significant improvement was seen in both groups the children treated with TENS clearly have the better outcome with approximately 60% increase in the number of dry nights. The effect was not gender related. The authors conclude that TENS represents an attractive treatment modality for children with monosymptomatic nocturnal enuresis.
TENS seems an attractive treatment option, being inexpensive and generally safe. It is tempting to speculate that children suffering from enuresis on the basis of bladder issues may benefit from such a treatment approach.
However, although the results of the study are promising, the main limitation of the study is the design used as TENS was applied concomitantly with behavioral therapy and children receiving TENS were offered more consultations than the control group. It can be therefore difficult to differentiate between the effect of TENS and behavioral therapy.
Before TENS can be implemented in the treatment of monosymptomatic nocturnal enuresis further controlled studies are needed to confirm the efficacy as well as identify patient characteristics that can be used as prognostic factors for the response to TENS.
Parasacral transcutaneous electrical neural stimulation is widely used to treat hyperactive bladder in children and adults. Its use in nonmonosymptomatic enuresis has demonstrated improvement in number of dry nights. We assessed the effectiveness of parasacral transcutaneous electrical neural stimulation in the treatment of monosymptomatic primary enuresis.
MATERIALS AND METHODS:
This prospective randomized clinical trial included 29 girls and 16 boys older than 6 years with primary monosymptomatic enuresis. Children were randomly divided into 2 groups consisting of controls, who were treated with behavioral therapy, and an experimental group, who were treated with behavioral therapy plus 10 sessions of parasacral transcutaneous electrical neural stimulation. Neural stimulation was performed with the electrodes placed in the sacral region (S2/S3). Sessions always followed the same pattern, with duration of 20 minutes, frequency of 10 Hz, a generated pulse of 700 μs and intensity determined by the sensitivity threshold of the child. Sessions were done 3 times weekly on alternate days. Patients in both groups were followed at 2-week intervals for the first month and then monthly for 6 consecutive months.
Rate of wet nights was 77% in controls and 78.3% in the experimental group at onset of treatment (p = 0.82), and 49.5% and 31.2%, respectively, at the end of treatment (p = 0.02). Analyzing the average rate of improvement, there was a significantly greater increase in dry nights in the group undergoing neural stimulation (61.8%) compared to controls (37.3%, p = 0.0038). At the end of treatment percent improvement in children undergoing electrical stimulation had no relation to gender (p = 0.391) or age (p = 0.911).
Treatment of primary monosymptomatic enuresis with 10 sessions of parasacral transcutaneous electrical neural stimulation plus behavioral therapy proved to be effective. However, no patient had complete resolution of symptoms.